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The Washington State Supreme Court ruled last week that “psychiatric boarding”, whereby psychiatric patients are admitted to a hospital, but stay for prolonged periods in an emergency department--sometimes for hours or days, until psychiatric beds are available--violates the state’s Involuntary Treatment Act, and is therefore unconstitutional. While the practice may once have been considered inhumane or cruel, it is now illegal.

This new ruling stems from a 2013 case in Pierce County involving ten psychiatric patients who were treated in acute care facilities or emergency departments. The facilities, however, were not certified to deliver individualized psychiatric care. As a result of a lawsuit by the ten patients challenging their lack of appropriate care, the judge declared the practice of boarding illegal.

After Pierce County and the Department of Social and Health services appealed the ruling, the state Supreme Court fired back saying that such patients cannot be detained due to a lack of resources or funds, and no justification can be made for the state’s failure to provide for such ongoing care for recovery. The bottom line is that the the Supreme Court was compelled to enforce the states’s Involuntary Treatment act that stating that “each person involuntarily detained or committed pursuant to (the Act) shall have the right to adequate care and individualized treatment.”

While such boarding of psychiatric patients was once uncommon in Washington, it has now become more prevalent in emergency departments throughout the state. And statistics now place the state in poor standing--almost near the bottom—in the US for psychiatric-treatment beds per capita.

In fact, according to an analysis by the Seattle Times in 2013, boarding increased fivefold from 2009 to 2012. In some cases, patients waited days or even months in order to be placed in long term care.

In Washington, patients who are involuntarily committed must be brought before a judge after 72 hours. The judge then makes a decision whether to continue to detain the patient in the emergency department. Some of these patients may then be returned to the same ED.

Such patients may remain in less than ideal locations such as hallways, administered psychiatric medications, but having no formal access to psychiatric evaluation and care. Staff members including nurses and administrative staff have in some cases faced verbal or physical threats from such patients, with their safety being a concern.

Washington’s longstanding position has been that it is safer to board such patients than to release potentially dangerous patients back to the community who may live on the streets. But while there has been a sharp increase in boarding, the funding to treat them has been significantly reduced over the past 15 years. In fact, the state now has 250 fewer psychiatric beds compared to six years ago, and has reduced funding by nearly 100 million dollars in programs designed to reduce boarding, according to a report in the Seattle Times. Whilethere have been recent increases in mental health funding by the state, more resources and solutions are necessary in order to help ease the burden on hospitals and acute care facilities.

Dr. Alex Rosenau, President of the American College of Emergency Physicians (ACEP), detailed several areas of concern as a result of this new potentially precedent-setting ruling declaring psychiatric boarding “unconstitutional”.

“This ruling is a well-intentioned first step toward solving the problem of psychiatric boarding,” Rosenau explained, “but it does not identify the resources to care for a patient in acute crisis, creating potential danger for the patient and the community. People in mental health crises often seek care in emergency departments because other parts of the health care system have failed them. Necessary resources must be available to these patients, such as inpatient psychiatric beds and staff; otherwise they will continue to be at risk.”

“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others. This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition,” added Rosenau.

“The ruling is a call to action, and our main objective must be to get every patient the right level of care. The next challenge is directed to hospital and community leaders to find the resources to care for them,” concluded Rosenau.

84 percent of emergency physicians report that psychiatric patients are being “boarded” in their emergency department, according to an ACEP poll of its members in early 2014. In fact, nearly 91 percent of emergency physicians participating in the ACEP survey explained that boarding has led to violent behavior by distressed psychiatric patients, distracted staff or bed shortages, all of which may harm patients. The practice has now spread to more rural areas, leading to a greater level of concern as resources to treat such patients continue to shrink.

Solutions to the problem

Rosenau and ACEP offer up a number of possible solutions including increasing hospital inpatient staffing and capacity. More psychiatric inpatient beds would help to alleviate boarding for those patients who need admission for inpatient care.Another potential solution involves more effective and streamlined case management of patients to decrease psychiatric emergencies. A greater presence of case managers to interface with families in crisis, along with their psychiatrists, could have the ability to reduce ED visits for acute psychiatric complaints.

In addition, by having more effective outpatient community plans to handle increased patient capacity in the ED may also offer some ability to divert patients from the ED who might not require admission.